Validating an instrument for selecting interventions to change physician practice patterns: a Michigan consortium for family practice research study - Original Research

Journal of Family Practice, Nov, 2002 by Lee A. Green, Daniel W. Gorenflo, Leon Wyszewianski

* OBJECTIVES The goal of this study was to develop a psychometric instrument that classified physicians' response styles to new" information as seekers, receptives, traditionalists, or pragmatists. This classification was based on specific combinations of 3 scales: (a) belief in evidence vs experience as the basis of knowledge, (b) willingness to diverge front common or previous practice, and (c) sensitivity to pragmatic concerns of practice. The instrument will help focus efforts to change practice more accurately.

* STUDY DESIGN This was a cross-sectional study of physician responses to a psychometric instrument. Paper-and-pencil survey forms were distributed to 3 waves of physicians, with revision for improved internal consistency at each iteration.

* POPULATION Participants were 1393 primary care physicians at continuing education events in the Midwest or at primary care clinic sites in the Veterans' Health Administration system.

* OUTCOMES MEASURED Internal consistency was measured by factor analysis with orthogonal rotation and Cronbach's alpha.

* RESULTS A total of 1287 usable instruments were returned (106, 1120, and 61 in the 3 iterations, respectively), representing approximately three fourths of distributed forms. Final scale internal consistencies were a = 0.79, b = 0.74, and c = 0.68. The patterns of scores on the 3 scales were consistent with the predictions of the theoretical scheme of physician types. The "seeker" type was the rarest, at fewer than 3%.

* CONCLUSIONS It is possible to reliably classify physicians into categories that a theoretical framework predicts will respond differently to different interventions for implementing guidelines and translating research findings into practice. The next step is to demonstrate that the classification predicts physician practice behavior.

* KEYWORDS Patterns, physician's practice; education, medical, continuing; practice guidelines; decision making; psychometric instruments. (J Fam Pract 2002; 51:938-942)

KEY POINTS FOR CLINICIANS

* One size probably does not fit all when bringing physicians new information that might change their practice.

Physicians differ measurably in what they consider credible sources of information, the weight they assign to practical concerns, and their willingness to diverge from group norms in practice.

* Interventions that bring new knowledge into practice can be tailored to physicians' perspectives. Further research may show this approach to be more useful to physicians and more likely to succeed than current approaches.

We previously proposed a theoretical framework for selecting the most effective strategies for changing physicians' practice patterns. (1) This framework called for classifying physicians into 4 categories based on how they respond to new information about the effectiveness of clinical practices, then selecting the strategy best suited to each physician's response style. In this paper we describe the development and validation of a psychometric instrument to classify, physicians into the 4 categories. This is one more element in our ongoing effort to answer, rigorously and specifically, basic questions about the adoption of evidence-based practices; for example, how can we increase physicians' use of proven interventions, such as [beta]-blockers after myocardial infarction or tight blood pressure control for patients with type 2 diabetes? How can we reduce physicians' use of disproved therapies, such as oral [beta]-agonist tocolytics for preterm labor or antibiotics for viral illnesses?

The literature is rife with examples of single-mode and multimode studies using educational interventions, positive and negative incentives, group and individualized feedback, sanctions, regulations, academic detailing, and patient-demand interventions to bring about changes in physician practice. (2-5) Advocates of these approaches cite published examples of their" success in changing clinical practices; in all cases, however, published and unpublished instances of failure exist as well. The lack of a consistent pattern of success or failure has led to a growing recognition that no single strategy will ever be a "magic bullet" (5); therefore, the selection of practice change strategies must be based on specific situations and settings. (6-8) However, it is still not known what characteristics of the setting matter most and which approach will work in a specific setting and situation.

We believe that one key factor in selecting effective strategies is the audience. Businesses learned long ago that market segmentation, in which products are advertised differently to people who have different needs, values, and views, is crucial to success in sales. Similarly, our theoretical framework posits that selecting the most appropriate change strategy requires first classifying clinicians according to how they respond to new information about the effectiveness of clinical strategies. We distinguish 4 classification categories: seekers, receptives, traditionalists, and pragmatists. (1)